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Nursing Practice Standard

Background of Oropharyngeal Airway

Management of the airway of a patient and relieving any kind of obstruction in the airway is a pre-requisite for establishing the breathing of a patient. Airway management entails within itself a set of techniques, manoeuvres, medical procedures that assist in removing any kind of obstruction or blockage in the airway. It helps in establishing the patency of the airway in order to create a pathway for the exchange of air between the atmosphere and the lungs (Brindley et al., 2017). It helps in establishing adequate circulation and ventilation which is an absolute basic for maintaining life.

It is done when the patient is unconscious, when the patient has an obstructed airway or when the patient is in need of ventilation. The blockage or the obstruction can occur at any level, beginning from either the mouth or nose and going till the level of bronchi. In cases with known or unknown hypoxia, oxygen should also be administered along with the manual management of the airway passage.It is an essential skill for clinicians who are caring for critically injured patients or ill patients as well. It is a basic skill whose absence can lead to avoidable deaths and unnecessary admissions of patients in critical care as well. Various types of devices such as extra-glottic, oral or nasal endotracheal intubation, surgical methods for maintenance and bag mask ventilation techniques as well are used. Numerous methods for establishing definitive control of the airway as well as the associated devices currently available to maintain control are described (Brindley et al., 2017). Once the airway is maintained, it is important to ensure adequate oxygenation and ventilation through the airway.

Airway management involves two kinds of techniques such as basic and advanced. Basic techniques involve head and neck maneuvering, back blows and abdominal thrust. Advanced techniques involve specific training and specialization by the health professionals. Medical practitioners and registered nurses are trained specifically in the techniques based on specific standards and guidelines. Advanced techniques involve both supraglottic and infraglottic techniques. Oropharyngeal and nasopharyngeal airway management are a part of the supraglottic techniques and can be directly performed by the RN as well, whereas the infra-glottic techniques like tracheal intubation, cricithyrotomy and laryngeal mask placement and face-mask placement as well (Driver et al., 2020).

 The infra-glottic techniques are practiced by medical practitioners with assistance and further management from the nurses. The Nursing practice standards guide the nurses in performing their duties responsibly. They are basic statements giving an adequate description of the current knowledge, practice and quality of learning. They also help act like a self-evaluation tool for the nurses (Ossenberg et al., 2019). The NPS guidelines being discussed here involve the standards for carrying out airway management and the various techniques. More specifically, supra-glottic techniques like oropharyngeal airway placement will be discussed. 

Current NPS Practice Guideline for Oropharyngeal Airway Sizing and Placement

The oropharyngeal airway is used as a supra-glottic device to clear the airway in patients who are unconscious. They are used commonly in the emergency care, pre-hospital and for post anaesthesia short term airway management, or when manual methods are not enough to maintain the open airway. The basic technique involves sizing of the airway tube. Then, opening the patient’s mouth and checking for any foreign object in the mouth followed by suctioning of the mouth for oral debris. Insertion of the airway in the oral cavity is done when the airway points upwards and rotated at 180 degrees angle. The airway is then advanced till it reaches the pharynx. It is reassessed again for blockage or obstruction followed by providing mechanical ventilation. The exact verbatim for the current practice is as follows-

 “Sizing of the oropharyngeal airway- Line up the oropharyngeal airway to the side of the patient’s face, with opening at level of patient’s incisors and length of airway to co-relate with the angle of patient’s jaw.”

New Suggestion for Practice

The basic technique involves sizing of the airway tube. This sizing will involve many techniques. Using predefined sizes is also helpful as the sizes have been found to be most appropriate based on ventilation and endoscopy. Then, opening the patient’s mouth and checking for any foreign object in the mouth followed by suctioning of the mouth for oral debris. Insertion of the airway in the oral cavity is done when the airway points upwards and rotated at 180 degrees angle. The airway is then advanced till it reaches the pharynx. It is reassessed again for blockage or obstruction followed by providing mechanical ventilation. The exact verbatim for the new suggestion of practice is as follows-

“Sizing of the oropharyngeal airway- “Using size 9 and 8 airways for men and women, respectively, have been proposed as most appropriate based on endoscopy and ventilation.”

Rationale

Sizing of the oropharyngeal tube helps in determining the correct position that will allow proper ventilation and prevent obstruction of the airway. Manual external facial measurements have been used to determine the appropriate size of the oropharyngeal tube in maintaining the patency of the airway. Incorrect sizing is a major problem and issue and can lead to more obstruction or can lead to leakages and no resolution of the obstruction. A long airway may cause encroachment upon the larynx and cause laryngospasm. An airway that is too short may actually cause pushing of the tongue posteriorly and exacerbate obstruction (Kim at al., 2014). Hence, effective ways to determine the sizes of the tube and correct placement should be done in order to maintain the effectiveness of the procedure.

Two manual techniques have been proposed in the past for the measurement of the oropharyngeal tube in the patient. The two external facial measurements that have been recommended as reference criteria for estimating appropriate oropharyngeal airway sizes are as follows: the distances between the maxillary incisors to the angle of the mandible, and that from the corner of the mouth to the angle of the mandible. A randomized cross-over study done in 2016 showed that in the maxillary incisors to the angle of the mandible group, there was clear manual ventilation through the oropharyngeal airway in all patients, whereas partially obstructed ventilation was observed in 6% of patients in the corner of the mouth to the angle of the mandible group. In the maxillary incisors to the angle of the mandible group, mechanical ventilation through the oropharyngeal airway was adequate in all patients but in the corner of the mouth to the angle of the mandible group, inadequate ventilation was observed in 7% patients. In the maxillary incisors to the angle of the mandible group, the endoscopy did not identify any patient with complete obstruction of the airway by the tongue but in the corner of the mouth to the angle of the mandible group, 40% of patients had complete obstruction by the tongue. In the maxillary incisors to the angle of the mandible group, the tip of the airway passed beyond the tip of the epiglottis in 22% of patients, in contrast, none of the airways in the corner of the mouth to the angle of the mandible group passed beyond the tip of the epiglottis. This manual technique has been used always (Kim et al., 2016).

However, another randomized control trial carried out in 2017 for more than 150 patients requiring intubation showed that appropriate sizing of the oropharyngeal tubes instead of using mechanical measurement established better ventilation and reduced the obstruction as well. In this study, the adequacy for manual and pressure-controlled mechanical ventilation and views at the distal end of each airway was assessed using a fiber-optic bronchoscope with various airway sizes (7, 8, 9, 10, and 11). Endoscope was used to visualize the level of obstruction. The results showed that for men, size 9, 10, and 11 airways permitted clear manual and adequate mechanical ventilation; size 7 and 8 airways caused partially obstructed manual and inadequate mechanical ventilation. On endoscopy, size 7 and 8 airways caused complete obstruction by the tongue; size 10 and 11 airways either touched or passed beyond the tip of the epiglottis. For women, the size 7 airway caused partially obstructed manual and inadequate mechanical ventilation; size 9 and 10 airways provided clear manual and adequate mechanical ventilation. The size 8 airway permitted clear manual ventilation, though mechanical ventilation was inadequate in one patient. On endoscopy, the size 7 airway caused complete obstruction in >50% of women; size 9, 10, and 11 airways either touched or passed beyond the tip of the epiglottis.(Kim et al., 2017).

It can be concluded that after checking for adequate ventilation in conjunction with an acceptable endoscopic view, size 9 and size 8 oropharyngeal airways appear to be the most appropriate sizes for clinical use in men and women, respectively. Another study by Kim & Park, 2011, established that oropharyngeal airway of size No. 9 is likely to be most suitable for use in adults. Looking at the evidence, it can be safely concluded that pre-sized airways can also be used as an alternative to manual sizing for measuring the oropharyngeal airway.

Reference for Oropharyngeal Airway Management

Brindley, P. G., Beed, M., Law, J. A., Hung, O., Levitan, R., Murphy, M. F., & Duggan, L. V. (2017). Airway management outside the operating room: how to better prepare. Canadian Journal of Anesthesia64(5), 530-539.

Driver, B. E., Mosier, J., & Brown III, C. A. (2020). The importance of the intubation process for the safety of emergency airway management. Academic Emergency Medicine.

Higgs, A., McGrath, B. A., Goddard, C., Rangasami, J., Suntharalingam, G., Gale, R., ... & of Anaesthetists, R. C. (2018). Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anaesthesia120(2), 323-352.

Kim, H. J., Kim, S. H., Min, J. Y., & Park, W. K. (2017). Determination of the appropriate oropharyngeal airway size in adults: Assessment using ventilation and an endoscopic view. The American Journal of Emergency Medicine35(10), 1430-1434.

Kim, H. J., Kim, S. H., Min, N. H., & Park, W. K. (2016). Determination of the appropriate sizes of oropharyngeal airways in adults: correlation with external facial measurements: A randomised crossover study. European Journal of Anaesthesiology (EJA)33(12), 936-942.

Kim, J. E., & Park, W. K. (2011). Determination of the proper size of oropharyngeal airway: Correlation with external body measurements: 19AP2-4. European Journal of Anaesthesiology (EJA)28, 228.

Kim, S. H., Kim, J. E., Kim, Y. H., Kang, B. C., Heo, S. B., Kim, C. K., & Park, W. K. (2014). An assessment of oropharyngeal airway position using a fibreoptic bronchoscope. Anaesthesia69(1), 53-57.

Ossenberg, C., Mitchell, M., & Henderson, A. (2019). Adoption of new practice standards in nursing: Revalidation of a tool to measure performance using the Australian registered nurse standards for practice. Collegian.

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

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